Financial Assessments Form

The purpose of this form is for you to give us the information we need to work out your contribution towards Care & Support services provided by London Borough of Bromley.

PLEASE READ THE FOLLOWING NOTES PRIOR TO COMPLETION OF THIS FORM.

1. Where a person is provided with Adult Social Care & Support Services (Personal Budgets, Domiciliary Care, Supported Living, Day Care Attendance or Care in a Residential or Nursing Home) Local Authorities, by Law, have the right to charge for the services provided.

2. Please ensure that the form is completed fully and accurately. Provide documentary evidence of all your income and savings and assets via the evidence upload facility of this form. (If you are unable to send digitally we accept photocopies but any original documents sent to us will be returned by recorded delivery).

3. If someone is completing this form on your behalf please provide documentary evidence of the official capacity under which they act for you. For example, Court of Protection Deputyship, Receivership Order, Power of Attorney document, Appointeeship with DWP, etc.

4. Non-completion of this form, or refusal to provide evidence of your finances (e.g. Bank statements, share certificates, proof of investments, etc.) will result in you being charged the full cost for your Care & Support Services.

5. Incomplete forms or missing items of evidence may result in a delay to your financial assessment. This means that a debt may accumulate. In these cases, all charges will be back-dated to the start of the Care & Support Service package.

6. You will be notified in writing the outcome of your financial assessment. If you are required to make a contribution towards your care package, the assessment letter will show you exactly how the charge has been calculated.

Section 1

About yourself
Are you requesting the financial assessment for adult social care for yourself or someone else?

If the local authority has not seen evidence that you act on the applicant's behalf in a formal capacity (appointee, deputy, power of attorney, receiver) you will need to provide evidence of this. If you do not act in a formal capacity then we will need a signed third party authorisation form).
Your property address
Your contact information
Applicant Details
Please provide last home address
Property address
Contact information

Section 2

Household Details
Do you have a partner?

Partner information
Does your spouse/partner/civil partner reside at the same address as you?

Partner's address

Does anyone else live at this address?

Occupant information
Occupant 1
Is this person incapacitated?

Remove person
Add another person
Does anyone else look after your finances for you?

Who looks after your finances?

Address details

Contact information

We will need to see proof that someone looks after your finances for you.

Section 3

Capital and savings

You do not have to complete this form or tell us anything about your finances. If you choose not to, you will have to pay the full cost of any Care & Support Services provided to you by London Borough of Bromley.

Are you prepared to disclose details of your financial circumstances?

By clicking on the Next button you understand that you will be required to pay the full cost of any Care & Support Services provided to you by London Borough of Bromley

By clicking on the Next button you understand that you will be required to pay the full cost of any Care & Support Services provided to you by London Borough of Bromley and will also have to pay the Full Cost Arrangement Fee, details of which can be seen here.

Do you have capital or savings over £23,250?

By clicking on the next button you understand that you will be required to pay the full cost of any Care and Support Services provided to you by London Borough of Bromley. However in order to fully assess your entitlement to support for Care and Support Services and consider when you may be entitled to support in the future, please continue to complete the form and provide details of your financial circumstances.

Please give details of all savings and investments held in your name and in joint names. A bank or building society account will only be treated as a joint account if the funds going into the account are from all the named parties of the account. Otherwise the balance in the account will be treated as belonging only to the person(s) whose funds or income go into the account

Do you have any capital from an equity release scheme?

£
Have you received a lump sum from a drawn down pension?

£
Have you ever made a claim for or received compensation for a Personal Injury?

£
Any other savings or investments not listed above?

Section 4

Income

Please provide details of your Income or any Income in Joint Names

Do you receive any income from Benefits?

Benefits income information
Benefit Income 1
£
Remove benefit income
Add another benefit income
Do you receive income from a personal/private or occupational pension/Annuity?

Pension income information
Pension Income 1
£
Remove pension income
Add another pension income
Do you receive any rental income?

Rental income information
Rental Income 1
£
Property 1 details
Remove rental income
Add another rental income
Do you receive any other income not listed above?

Other income information
Other Income 1
£
Remove other income
Add another income

Section 5

About where you live
Do you own the property you live in?

£
Is the property jointly owned?

Is there an outstanding mortgage on the property?

£
I own the property I lived in before I moved to a care home:

£
Is the property jointly owned?

Is there an outstanding mortgage on the property?

£
Is the property currently rented out?

£
I owned the property I lived in before I moved to a care home:

Property details
Was the property jointly owned?

£
I own or previously owned another property in the UK or abroad:

Property information
Additional property 1
£
Is(was) the property jointly owned?

Is the property currently rented out?

£
Remove property
Add another property
I live with family in their home:

I rent a room:

I rent my home (private landlord):

I rent my home (Council):

Section 6

Outgoings
Fixed Outgoings

Please provide details of your outgoings.Please DO NOT include Utility Bills like Gas, Electric, Water, Phone, etc.

£
£
£
£
£
£
£
£
£
Gifts

The Council accepts your right to spend your income and assets as you like and to make Gifts to friends and family. However, the Council has a Statutory duty to ensure that this is not done to avoid paying or to reduce the amount paid for Care & Support Services provided by the Council.

Have you made any gifts to family or friends, this includes transfers of property?

Gift information
Gift 1
£
Remove gift
Add another gift

Section 7

Confirmation of supplied information

Below is confirmation of the details you have completed in your application.

Section 1 - About yourself

Are you requesting the financial assessment for adult social care for yourself or someone else?

 

Your name

 

Contact address:

 

Email address:

 

Primary number:

 

Secondary number:

 

Relationship to claimant:

 

Capacity in which you act:

 

Applicant details

Applicant name

 

Date of birth:

 

National insurance number:

 

Please confirm your current circumstances

 

Care Home name

 

Last home address

 

Address:

 

Email:

 

Primary number:

 

Secondary number:

 

Section 2 - Household details

Do you have a partner?

 

Partner name:

 

Partner Date of birth:

 

Partner National insurance number:

 

Does your spouse/partner/civil partner reside at the same address as you?

 

Where does your partner live?

 

Partner address:

 

Does anyone else live at this address?

 

 

Occupant name:

 

Occupant date of birth:

 

Occupant relationship:

 

please provide more detail about this person:

 

Is this person incapacitated?

 

Does anyone else look after your finances for you?

 

Financial aid name:

 

Financial aid address:

 

Financial aid email:

 

Financial aid telephone number:

 

Financial aid mobile number:

 

Relationship to you:

 

Capacity in which the person acts:

 

Section 3 - Capital and Savings

Are you prepared to disclose details of your financial circumstances?

 

Do you have capital or savings over £23,250?

 

Do you have any capital from an equity release scheme?

 

Amount received:

 

Date received:

 

Have you received a lump sum from a drawn down pension?

 

Amount received:

 

Date received:

 

Have you ever made a claim for or received compensation for a Personal Injury?

 

Amount received:

 

Date received:

 

Any other savings or investments not listed above?

 

Please specify:

 

Section 4 - Income

Do you receive any income from employment?

 

 

Name of person working:

 

Income type:

 

Employer/Company Name:

 

Amount paid:

 

Frequency paid:

 

Hours worked per week:

 

Do you receive any income from benefits?

 

 

Name of person receiving Benefit:

 

Type of Benefit received:

 

Amount paid:

 

Frequency paid:

 

Do you receive income from a personal/private or occupational pension/Annuity?

 

 

Person receiving Income:

 

Type:

 

Company Name:

 

Amount received:

 

Frequency received:

 

Do you receive any other income not listed above?

 

 

Person receiving Income:

 

Type:

 

Company Name:

 

Amount received:

 

Frequency received:

 

Do you receive any rental income?

 

 

Amount received:

 

Rental address:

 

Additional information you wish to provide about this income::

 

Section 5 - Property details

Do you own the property you live in?

 

Approximate value of property(if known)

 

Is the property jointly owned?

 

Name of Joint owner(s):

 

Is there an outstanding mortgage on the property?

 

Outstanding balance:

 

Mortgage type:

 

I own the property I lived in before I moved to a care home:

 

Property Address:

 

Approximate value of property(if known)

 

Is the property jointly owned?

 

Name of Joint owner(s):

 

Is there an outstanding mortgage on the property?

 

Outstanding balance:

 

Mortgage type:

 

Is the property currently rented out?

 

Amount received:

 

Frequency received:

 

I owned the property I lived in before I moved to a care home:

 

Property Address:

 

Was the property jointly owned?

 

Name of Joint owner(s):

 

Property sale value:

 

Date sold:

 

I own or previously owned another property in the UK or abroad:

 

 

Property address:

 

Value of property now or when sold:

 

Date of sale (if appropriate):

 

Is(was) the property jointly owned?

 

Name of Joint owner(s):

 

Is the property currently rented out?

 

Amount received:

 

Frequency received:

 

I live with family in their home:

 

I rent a room:

 

I rent my home (private landlord):

 

I rent my home (Council):

 

Anything else you would like to tell us about properties you own or previously owned and sold or transferred?

 

Section 6 - Outgoings

Please provide details of your outgoings.Please DO NOT include Utility Bills like Gas, Electric, Water, Phone, etc.

Amount

Frequency

Service Charges:

 

 

Mortgage Repayment:

 

 

Home Improvement loan:

 

 

Ground rent:

 

 

Rent (excluding House Benefit):

 

 

Council Tax (excluding Council Tax Support):

 

 

Court orders:

 

 

Linkline:

 

 

Other:

 

 

Please Specify:

 

Have you made any gifts to family or friends, this includes transfers of property?

 

 

Recipient Name:

 

Recipient relationship:

 

Amount gifted:

 

Date gifted:

 

Purpose:

 

Section 8

Declaration

It has been explained to me by Social Services that:

  • All Care and Support Services provided by London Borough of Bromley are chargeable and the purpose of completing a financial assessment form is to determine the amount I will need to pay towards any Care and Support Services provided to me.
  • The Financial Assessment Team will conduct a financial assessment and notify me in writing of the amount I will be required to pay for the Care and Support Services.
  • I agree that personal information I have provided to the Department for Work and Pensions (DWP) for the purpose of claiming welfare benefits may be passed by them to the London Borough of Bromley, for the purposes of assessing charges for the cost of my Social Services Care.
  • I authorise the London Borough of Bromley to divulge my basic personal information to the Department for Work and Pensions when requesting the provision of assistance for the purpose of maximising my benefits and income. I understand that I may withdraw my consent to the disclosure of such information by notifying, in writing , my local DWP office and London Borough of Bromley.
  • I agree that the information provided in my assessment may be shared with social care and health staff, services and providers who can contribute to my care and any agencies acting on behalf of these organisations.
  • I undertake to notify the London Borough of Bromley if my circumstances change.
  • I understand that the information given on this form may be stored on a computer and could be shared with other appropriate Council Departments and outside agencies for registered purposes under the Data Protection Acts and General Data Protection Regulations (GDPR).
  • I understand and accept that false or inaccurate information may result in civil recoveries of any discounts wrongly received and criminal prosecution against me by the London Borough of Bromley.

You are signing to say you have read, understood and accepted the above. You will be notified in writing of the outcome of your financial assessment. If you are required to make a contribution towards your care package, the assessment letter will show you exactly how the charge has been calculated.

Privacy Statement

London Borough of Bromley is under duty to protect the public funds it administers, and to this end, may use the information you have provided on this form for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing or administering public funds for these purposes.